Title: Atrial fibrillation: From pathophysiology to catheter ablation
Abstract: Recent studies have provided new insight into the mechanisms of atrial fibrillation (AF). 1 Allessie M.A. Boyden P.A. Camm A.J. Kleber A.G. Lab M.J. Legato M.J. Rosen M.R. Schwartz P.J. Spooner P.M. Van Wagoner D.R. Waldo A.L. Pathophysiology and prevention of atrial fibrillation. Circulation. 2001; 103: 769-777 Crossref PubMed Scopus (630) Google Scholar Based on these advances in the understanding of AF pathophysiology, different catheter ablation techniques for treatment of AF are evolving. The mechanisms of AF are heterogeneous and likely differ in individual patients. In addition to the important role of the pulmonary veins (PVs) in the initiation and perpetuation of AF, 2 Haissaguerre M. Jais P. Shah D.C. Takahashi A. Hocini M. Quiniou G. Garrigue S. Le Mouroux A. Le Metayer P. Clementy J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339: 659-666 Crossref PubMed Scopus (6482) Google Scholar non-PV arrhythmogenic foci, 3 Lin W.S. Tai C.T. Hsieh M.H. Tsai C.F. Lin Y.K. Tsao H.M. Huang J.L. Yu W.C. Yang S.P. Ding Y.A. Chang M.S. Chen S.A. Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation. 2003; 107: 3176-3183 Crossref PubMed Scopus (609) Google Scholar left atrial (LA) substrates, 4 Nademanee K. McKenzie J. Kosar E. Schwab M. Sunsaneewitayakul B. Vasavakul T. Khunnawat C. Ngarmukos T. A new approach for catheter ablation of atrial fibrillation mapping of the electrophysiologic substrate. J Am Coll Cardiol. 2004; 43: 2044-2053 Abstract Full Text Full Text PDF PubMed Scopus (1714) Google Scholar and autonomic innervation of the LA 5 Scherlag B.J. Yamanashi W. Patel U. Lazzara R. Jackman W.M. Autonomically induced conversion of pulmonary vein focal firing into atrial fibrillation. J Am Coll Cardiol. 2005; 45: 1878-1886 Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar have been implicated in the pathogenesis of AF. Therefore, catheter ablation techniques that target only the PVs have demonstrated only modest efficacy and may not be sufficient in all patients with AF. Several investigators have used various hybrid ablation approaches and reported a higher success rate than PV isolation and/or encirclement alone for curative ablation of AF. 6 Ouyang F. Bansch D. Ernst S. Schaumann A. Hachiya H. Chen M. Chun J. Falk P. Khanedani A. Antz M. Kuck K.H. Complete isolation of left atrium surrounding the pulmonary veins new insights from the double-Lasso technique in paroxysmal atrial fibrillation. Circulation. 2004; 110: 2090-2096 Crossref PubMed Scopus (677) Google Scholar , 7 Pappone C. Manguso F. Vicedomini G. Gugliotta F. Santinelli O. Ferro A. Gulletta S. Sala S. Sora N. Paglino G. Augello G. Agricola E. Zangrillo A. Alfieri O. Santinelli V. Prevention of iatrogenic atrial tachycardia after ablation of atrial fibrillation a prospective randomized study comparing circumferential pulmonary vein ablation with a modified approach. Circulation. 2004; 110: 3036-3042 Crossref PubMed Scopus (310) Google Scholar , 8 Hocini M. Jais P. Sanders P. Takahashi Y. Rotter M. Rostock T. Hsu L.F. Sacher F. Reuter S. Clementy J. Haissaguerre M. Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation a prospective randomized study. Circulation. 2005; 112: 3688-3696 Crossref PubMed Scopus (399) Google Scholar Recent studies from Haissaguerre et al 9 Haissaguerre M. Sanders P. Hocini M. Takahashi Y. Rotter M. Sacher F. Rostock T. Hsu L.F. Bordachar P. Reuter S. Roudaut R. Clementy J. Jais P. Catheter ablation of permanent and persistent atrial fibrillation Critical structures for termination. J Cardiovasc Electrophysiol. 2005; 16: 1125-1137 Crossref PubMed Scopus (604) Google Scholar , 10 Haissaguerre M. Hocini M. Sanders P. Sacher F. Rotter M. Takahashi Y. Rostock T. Hsu L.F. Bordachar P. Reuter S. Roudaut R. Clementy J. Jais P. Catheter ablation of long lasting persistent atrial fibrillation Clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol. 2005; 16: 1138-1147 Crossref PubMed Scopus (587) Google Scholar showed a wide divergence in the ablation sites requiring termination in patients with persistent AF. Oral et al 11 Oral H. Chugh A. Good E. Sankaran S. Reich S.S. Igic P. Elmouchi D. Tschopp D. Crawford T. Dey S. Wimmer A. Lemola K. Jongnarangsin K. Bogun F. Pelosi Jr, F. Morady F. A tailored approach to catheter ablation of paroxysmal atrial fibrillation. Circulation. 2006; 113: 1824-1831 Crossref PubMed Scopus (176) Google Scholar demonstrated that a tailored ablation approach using noninducibility as the endpoint is feasible and efficacious for elimination of paroxysmal AF. This limited ablation approach is more advantageous than a standardized and extensive ablation strategy because it avoids unnecessary radiofrequency applications and thus the risk of serious complications, such as atrial-esophageal fistula. 12 Cummings J.E. Schweikert R.A. Saliba W.I. Burkhardt J.D. Kilikaslan F. Saad E. Natale A. Atrial-esophageal fistulas after radiofrequency ablation. Ann Intern Med. 2006; 144: 572-574 Crossref PubMed Scopus (189) Google Scholar Although these studies suggest that an individualize ablation approach can be used, the optimal method for identifying the prominent triggers, the substrate, or both in individual patients remains unclear.
Publication Year: 2006
Publication Date: 2006-08-01
Language: en
Type: letter
Indexed In: ['crossref', 'pubmed']
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